Healthcare Provider Details

I. General information

NPI: 1356442180
Provider Name (Legal Business Name): JEN TIEN WUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9878
  • Fax: 212-305-8980
Mailing address:
  • Phone: 212-305-9878
  • Fax: 212-305-8980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number111954
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number111954
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: